NSG 521 Module 12 Assessment Of The
Hospitalized Client – Questions With Reliable
Solutions
Save
Terms in this set (191)
As a nurse, you are True
continuously assessing
patients. When there are
signs of an emergent,
acute, or urgent situation,
you perform immediate
assessments and
interventions with a team
of providers.
,Acute and urgent True
situations such as the
following warrant
immediate attention and
interventions:
A respiratory rate lower
than 8 or greater than 28
breaths/min
An acute change in
oxygen saturation below
90% despite oxygen
administration
A threatened airway
Acute change in systolic
BP to less than 90 mm Hg
or a sustained increase in
diastolic BP greater than
110 mm Hg
Acute change in heart
rate to fewer than 50 or
greater than 120
beats/min
New-onset chest pain or
signs of acute myocardial
infarction
An acutely cold,
cyanotic, or pulseless
extremity
Confusion, agitation, or
delirium
Unexplained lethargy or
acute altered mental
status
Difficulty speaking or
signs of acute stroke
Acute change in pupillary
response
New seizure
Temperature greater than
39.0°C (102.2°F)
,Uncontrolled pain
Acute change in urine
output less than 50 ml
(about 1¾ oz) over 4
hours
Acute bleeding
Suspected severe sepsis
(AHRQ, 2013a)
An urgent assessment is True
warranted for an acute
change in heart rate to
fewer than 50
beats/minute.
An urgent assessment is True
warranted when there is
an acute change in
pupillary response.
An urgent assessment is True
warranted for an acute
change in heart rate to
greater than 120
beats/minute.
An urgent assessment is True
warranted when acute
altered mental status
occurs.
An urgent assessment is True
warranted when an
extremity becomes
acutely cold.
An urgent assessment is True
warranted in the
presence of confusion,
agitation, or delirium.
, Perform a safety True
inspection of the
hospitalized patient and
environment, including
equipment. You will often
perform this assessment
during the change-of-
shift rounding or handoff
procedure. The purpose
is to assess the patient's
immediate medical
condition as well as
potential hazards such as
falls, impaired breathing,
malfunctioning
equipment or
complications from IV
lines, and intubation.
Hospitalized Client – Questions With Reliable
Solutions
Save
Terms in this set (191)
As a nurse, you are True
continuously assessing
patients. When there are
signs of an emergent,
acute, or urgent situation,
you perform immediate
assessments and
interventions with a team
of providers.
,Acute and urgent True
situations such as the
following warrant
immediate attention and
interventions:
A respiratory rate lower
than 8 or greater than 28
breaths/min
An acute change in
oxygen saturation below
90% despite oxygen
administration
A threatened airway
Acute change in systolic
BP to less than 90 mm Hg
or a sustained increase in
diastolic BP greater than
110 mm Hg
Acute change in heart
rate to fewer than 50 or
greater than 120
beats/min
New-onset chest pain or
signs of acute myocardial
infarction
An acutely cold,
cyanotic, or pulseless
extremity
Confusion, agitation, or
delirium
Unexplained lethargy or
acute altered mental
status
Difficulty speaking or
signs of acute stroke
Acute change in pupillary
response
New seizure
Temperature greater than
39.0°C (102.2°F)
,Uncontrolled pain
Acute change in urine
output less than 50 ml
(about 1¾ oz) over 4
hours
Acute bleeding
Suspected severe sepsis
(AHRQ, 2013a)
An urgent assessment is True
warranted for an acute
change in heart rate to
fewer than 50
beats/minute.
An urgent assessment is True
warranted when there is
an acute change in
pupillary response.
An urgent assessment is True
warranted for an acute
change in heart rate to
greater than 120
beats/minute.
An urgent assessment is True
warranted when acute
altered mental status
occurs.
An urgent assessment is True
warranted when an
extremity becomes
acutely cold.
An urgent assessment is True
warranted in the
presence of confusion,
agitation, or delirium.
, Perform a safety True
inspection of the
hospitalized patient and
environment, including
equipment. You will often
perform this assessment
during the change-of-
shift rounding or handoff
procedure. The purpose
is to assess the patient's
immediate medical
condition as well as
potential hazards such as
falls, impaired breathing,
malfunctioning
equipment or
complications from IV
lines, and intubation.
